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Floan Sachs G, Ourshalimian S, Jensen AR, Kelley-Quon LI, Padilla BE, Shew SB, Lofberg KM, Smith CA, Roach JP, Pandya SR, Russell KW, Ignacio RC. Machine learning to predict pediatric choledocholithiasis: A Western Pediatric Surgery Research Consortium retrospective study. Surgery 2023; 174:934-939. [PMID: 37580219 DOI: 10.1016/j.surg.2023.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/24/2023] [Accepted: 07/08/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND The purpose of this study was to accurately predict pediatric choledocholithiasis with clinical data using a computational machine learning algorithm. METHODS A multicenter retrospective cohort study was performed on children <18 years of age who underwent cholecystectomy between 2016 to 2019 at 10 pediatric institutions. Demographic data, clinical findings, laboratory, and ultrasound results were evaluated by bivariate analyses. An Extra-Trees machine learning algorithm using k-fold cross-validation was used to determine predictive factors for choledocholithiasis. Model performance was assessed using the area under the receiver operating characteristic curve on a validation dataset. RESULTS A cohort of 1,597 patients was included, with an average age of 13.9 ± 3.2 years. Choledocholithiasis was confirmed in 301 patients (18.8%). Obesity was the most common comorbidity in all patients. Choledocholithiasis was associated with the finding of a common bile duct stone on ultrasound, increased common bile duct diameter, and higher serum concentrations of aspartate aminotransferase, alanine transaminase, lipase, and direct and peak total bilirubin. Nine features (age, body mass index, common bile duct stone on ultrasound, common bile duct diameter, aspartate aminotransferase, alanine transaminase, lipase, direct bilirubin, and peak total bilirubin) were clinically important and included in the machine learning algorithm. Our 9-feature model deployed on new patients was found to be highly predictive for choledocholithiasis, with an area under the receiver operating characteristic score of 0.935. CONCLUSION This multicenter study uses machine learning for pediatric choledocholithiasis. Nine clinical factors were highly predictive of choledocholithiasis, and a machine learning model trained using medical and laboratory data was able to identify children at the highest risk for choledocholithiasis.
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Affiliation(s)
- Gretchen Floan Sachs
- Division of Pediatric Surgery, Department of Surgery, University of California San Diego, Rady Children's Hospital San Diego, CA
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children's Hospital Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Aaron R Jensen
- Department of Surgery, University of California San Francisco School of Medicine, CA; Division of Pediatric Surgery, University of California San Francisco Benioff Children's Hospitals, Oakland, CA. https://twitter.com/arjensenmd
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA. https://twitter.com/LKelley_Quon
| | | | - Stephen B Shew
- Division of Pediatric Surgery, Stanford Children's Hospital, Palo Alto, CA
| | - Katrine M Lofberg
- Division of Pediatric Surgery, Doernbecher Children's Hospital, Oregon Health and Science University, Portland, OR. https://twitter.com/katierussellmd
| | - Caitlin A Smith
- Department of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, WA
| | - Jonathan P Roach
- Department of Pediatric Surgery, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
| | - Samir R Pandya
- Department of Pediatric General and Thoracic Surgery, University of Texas Southwestern, Dallas, TX
| | - Katie W Russell
- Division of General Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, UT
| | - Romeo C Ignacio
- Division of Pediatric Surgery, Department of Surgery, University of California San Diego, Rady Children's Hospital San Diego, CA.
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Ignacio RC, Kelley-Quon LI, Ourshalimian S, Padilla BE, Jensen AR, Shew SB, Lofberg KM, Smith CA, Roach JP, Pandya SR, Russell KW, Wang K. Pediatric DUCT Score: A Highly Specific Predictive Model for Choledocholithiasis in Children. J Am Coll Surg 2023; 236:961-970. [PMID: 36786471 DOI: 10.1097/xcs.0000000000000650] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
BACKGROUND Current adult guidelines for the management of choledocholithiasis (CDL) may not be appropriate for children. We hypothesized adult preoperative predictive factors are not reliable for predicting CDL in children. STUDY DESIGN A multicenter retrospective cohort study was performed evaluating children (≤18 years of age) who underwent cholecystectomy for gallstone disease at 10 children's hospitals. Univariate and multivariable analyses were used to identify factors independently associated with CDL. Patients were stratified into risk groups demonstrating the presence of predictive factors for CDL. Statistical analyses were performed, and chi-square analyses were used with a significance of p < 0.05. RESULTS A total of 979 cholecystectomy patients were analyzed. The diagnosis of CDL was confirmed in 222 patients (22.7%) by magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, or intraoperative cholangiography. Three predictive factors were identified: (1) Dilated common bile duct ≥6 mm; (2) Ultrasound with Choledocholithiasis; and (3) Total bilirubin ≥1.8 mg/dL (pediatric DUCT criteria). Risk groups were based on the number of predictive factors: very high (3), high (2), intermediate (1), and low (0). The pediatric DUCT criteria demonstrated accuracies of >76%, specificity of >78%, and negative predictive values of >79%. Adult factors (elevated aspartate aminotransferase/alanine aminotransferase, pancreatitis, BMI, and age) did not independently predict CDL. Based on risk stratification, the high- and very-high-risk groups demonstrated higher predictive capacity for CDL. CONCLUSIONS Our study demonstrated that the pediatric DUCT criteria, incorporating common bile duct dilation, choledocholithiasis seen on ultrasound, and total bilirubin ≥1.8 mg/dL, highly predicts the presence of choledocholithiasis in children. Other adult preoperative factors are not predictive of common bile duct stone in children.
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Affiliation(s)
- Romeo C Ignacio
- From the Division of Pediatric Surgery, Department of Surgery, University of California San Diego, Rady Children's Hospital San Diego, San Diego, CA (Ignacio)
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA (Kelley-Quon, Ourshalimian, Wang)
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA (Kelley-Quon, Ourshalimian, Wang)
| | - Benjamin E Padilla
- Department of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ (Padilla)
| | - Aaron R Jensen
- Department of Surgery, University of California San Francisco School of Medicine, and Division of Pediatric Surgery, UCSF Benioff Children's Hospitals, Oakland, CA (Jensen)
| | - Stephen B Shew
- Department of Pediatric General Surgery, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, CA (Shew)
| | - Katrine M Lofberg
- Division of Pediatric Surgery, Doernbecher Children's Hospital, Oregon Health and Science University, Portland, OR (Lofberg)
| | - Caitlin A Smith
- Department of Pediatric General Surgery, Seattle Children's Hospital, Seattle, WA (Smith)
| | - Jonathan P Roach
- Department of Pediatric Surgery, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO (Roach)
| | - Samir R Pandya
- Department of Pediatric General and Thoracic Surgery, University of Texas Southwestern, Dallas, TX (Pandya)
| | - Katie W Russell
- Division of General Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, UT (Russell)
| | - Kasper Wang
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA (Kelley-Quon, Ourshalimian, Wang)
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Rauh JL, Ganapathy AS, Bosley ME, Rangecroft A, Zeller KA, Sieren LM, Petty JK, Pranikoff T, Neff LP. Making common duct exploration common-balloon sphincteroplasty as an adjunct to transcystic laparoscopic common bile duct exploration for pediatric patients. J Pediatr Surg 2023; 58:94-98. [PMID: 36283848 DOI: 10.1016/j.jpedsurg.2022.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 09/15/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Laparoscopic common bile duct exploration (LCBDE) at the time of cholecystectomy has well-established benefits for managing pediatric choledocholithiasis. However, providers increasingly favor ERCP pre-or-post laparoscopic cholecystectomy (ERCP+LC) due to perceived complexity of LCBDE. We refined a stepwise method employing wire-ready balloon dilation of the Sphincter of Oddi. This study compares outcomes of balloon sphincteroplasty (LCBDE+BSP) with standard transcystic LCBDE (LCBDE-STD) and ERCP+LC. METHODS We performed a retrospective chart review of pediatric patients who underwent LCBDE-STD and LCBDE+BSP since 2018. A report of consecutive choledocholithiasis patients prior to 2018 yielded an ERCP+LC cohort. Age, operative time, complications, and length of stay (LOS) were compared across all groups. Success rate and fluoroscopy time were compared between LCBDE groups. RESULTS 44 patients were identified (14:LCBDE-STD; 15:LCBDE+BSP; 15:ERCP+LC) . There was no difference in patient age or BMI. Operative time was longer in the LCBDE+BSP group (p =< 0.05). ERCP+LC demonstrated increased LOS (4.36 ± 2.78 vs 1.31 ± 0.93; p =< 0.05) and complications compared to LCBDE groups including three stent placements and one stent migration. LCBDE+BSP had a higher success rate than LCBDE-STD (100% vs 78%; p = 0.06). The three patients who failed LCBDE-STD required postoperative ERCP. Average fluoroscopy time was not significantly impacted by addition of sphincteroplasty. CONCLUSION Incorporating LCBDE into standard management of pediatric choledocholithiasis reduces LOS and avoids additional invasive procedures regardless of the specific technique employed. This stepwise approach to wire-ready cholangiography with balloon sphincteroplasty is a viable method for LCBDE that utilizes techniques familiar to pediatric surgeons and provides definitive management under a single anesthetic. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Jessica L Rauh
- Department of General Surgery, Wake Forest Baptist Medical Center, 1 Baptist Medical Center Blvd, Winston Salem, NC 27157, United States.
| | - Aravindh S Ganapathy
- Department of General Surgery, Wake Forest Baptist Medical Center, 1 Baptist Medical Center Blvd, Winston Salem, NC 27157, United States
| | - Maggie E Bosley
- Department of General Surgery, Wake Forest Baptist Medical Center, 1 Baptist Medical Center Blvd, Winston Salem, NC 27157, United States
| | - Alexa Rangecroft
- Wake Forest Baptist Medical Center School of Medicine, Winston Salem, NC, United States
| | - Kristen A Zeller
- Department of General Surgery, Section of Pediatric Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC, United States
| | - Leah M Sieren
- Department of General Surgery, Section of Pediatric Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC, United States
| | - John K Petty
- Department of General Surgery, Section of Pediatric Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC, United States
| | - Thomas Pranikoff
- Department of General Surgery, Section of Pediatric Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC, United States
| | - Lucas P Neff
- Department of General Surgery, Section of Pediatric Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC, United States
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Bosley ME, Zamora IJ, Neff LP. Choledocholithiasis-a new clinical pathway. Transl Gastroenterol Hepatol 2021; 6:35. [PMID: 34423156 DOI: 10.21037/tgh-20-172] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 05/18/2020] [Indexed: 01/07/2023] Open
Abstract
The incidence of cholecystectomy in children has increased considerably since the early 1990s. Management of gallbladder disease in children must include an awareness of choledocholithiasis treatment strategies. Both endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct exploration (open or laparoscopic) are accepted management techniques for choledocholithiasis. Laparoscopic cholecystectomy with preoperative or postoperative ERCP is at least a two-procedure process while cholecystectomy with laparoscopic common bile duct exploration (LCBDE) can provide definitive treatment in a single procedure under one anesthetic. Despite this, the trend over the last decade continues towards less LCBDE utilization in favor of ERCP. This trend has resulted in decreased familiarity with LCBDE by adult and pediatric surgeons and their trainees. Access to the necessary tools and education on the technical aspects can allow for successful single-stage treatment of choledocholithiasis by surgeons during laparoscopic cholecystectomy. This may include a pre-defined stepwise algorithm and understanding of all the equipment and resources necessary to perform a LCBDE. Ultimately, increased understanding of the equipment and procedural steps necessary for LCBDE will result in widened adoption of the technique and thus confer advantages to the patient such as decreased length of stay and fewer required anesthetics.
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Affiliation(s)
- Maggie E Bosley
- General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Irving J Zamora
- Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lucas P Neff
- Pediatric Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Romutis S, Slivka A. Pediatric ERCP: leaving no stone unturned. Gastrointest Endosc 2021; 94:318-320. [PMID: 33993990 DOI: 10.1016/j.gie.2021.03.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 03/27/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Stephanie Romutis
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Adam Slivka
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Barakat MT, Cholankeril G, Gugig R, Berquist WE. Nationwide Evolution of Pediatric Endoscopic Retrograde Cholangiopancreatography Indications, Utilization, and Readmissions over Time. J Pediatr 2021; 232:159-165.e1. [PMID: 33197494 DOI: 10.1016/j.jpeds.2020.11.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/19/2020] [Accepted: 11/10/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To analyze outcome and utilization trends over time of pediatric endoscopic retrograde cholangiopancreatography (ERCP) in an all-capture US population-level study. STUDY DESIGN Using the National Inpatient Sample (2005-2014) and National Readmission Database (2010-2014), we identified pediatric (age <20 years) hospitalizations during which ERCP was performed and assessed ERCP-associated readmissions. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify hospitalization diagnoses, comorbidities, and patient/hospital characteristics. Multivariate logistic regression analyses were performed to determine significant predictors (P < .05) of 30-day readmission. RESULTS A total of 11 060 hospitalized pediatric patients underwent ERCP between 2005 and 2014. Most were female (n = 8859; 81%), aged 14-20 years (n = 9342; 84%), and white (n = 4230; 45%). Most (85%) of ERCPs were therapeutic, and leading indications were biliary (n = 5350; 48%) and pancreatitis (n = 3218; 29%). Thirteen pecent of patients were readmitted post-ERCP. Odds for 30-day readmission were highest for patients with a history of liver transplantation, age 0-4 years, male sex, and obesity (P < .001 for each). Patients in both urban teaching and urban hospitals had much lower odds than those in rural hospitals for prolonged length of stay associated with ERCP. CONCLUSIONS These data represent a comprehensive study of nationwide trends in age-specific volumes and outcomes following ERCP in the pediatric population and provide important insights into trends in pediatric pancreaticobiliary disease management, as well as practice setting, patient characteristics, and patient comorbidities associated with pediatric post-ERCP outcomes, including readmission and length of stay.
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Affiliation(s)
- Monique T Barakat
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Lucille Packard Children's Hospital at Stanford University Medical Centerr, Stanford, CA; Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, CA
| | - George Cholankeril
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, CA
| | - Roberto Gugig
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Lucille Packard Children's Hospital at Stanford University Medical Centerr, Stanford, CA
| | - William E Berquist
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Lucille Packard Children's Hospital at Stanford University Medical Centerr, Stanford, CA.
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Bosley ME, Gaffley MWG, Zeller KA, Sieren LM, Petty JK, Pranikoff T, Neff LP. Balloon sphincteroplasty in pediatric laparoscopic common bile duct exploration. J Pediatr Surg 2021; 56:825-828. [PMID: 33349422 DOI: 10.1016/j.jpedsurg.2020.12.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 11/18/2020] [Accepted: 12/01/2020] [Indexed: 01/02/2023]
Abstract
The management of choledocholithiasis in children and teenagers is often a two-procedure process with laparoscopic cholecystectomy (LC) and either pre- or post-operative endoscopic retrograde cholangiopancreatography (ERCP). The addition of laparoscopic common bile duct exploration (LCBDE) during LC can provide definitive treatment for choledocholithiasis during a single anesthetic event. In an effort to minimize sedation and radiation exposure from fluoroscopy, we have employed dilating balloons via a transcystic approach to stretch the sphincter of Oddi with subsequent ductal flushing. We describe the technique of balloon sphincteroplasty as a straightforward adjunct within the pediatric surgeon's skill set to manage choledocholithiasis during LC and our clinical experience.
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Affiliation(s)
- Maggie E Bosley
- Wake Forest School of Medicine, General Surgery, Winston-Salem, NC, United States
| | - Michaela W G Gaffley
- Wake Forest School of Medicine, General Surgery, Winston-Salem, NC, United States
| | - Kristen A Zeller
- Wake Forest School of Medicine, Pediatric Surgery, Winston-Salem, NC, United States
| | - Leah M Sieren
- Wake Forest School of Medicine, Pediatric Surgery, Winston-Salem, NC, United States
| | - John K Petty
- Wake Forest School of Medicine, Pediatric Surgery, Winston-Salem, NC, United States
| | - Thomas Pranikoff
- Wake Forest School of Medicine, Pediatric Surgery, Winston-Salem, NC, United States
| | - Lucas P Neff
- Wake Forest School of Medicine, Pediatric Surgery, Winston-Salem, NC, United States.
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Abstract
BACKGROUND AND AIMS Endoscopic procedures are important for diagnosis and management of many gastrointestinal, liver, and biliary conditions in children. Therapeutic endoscopy procedures, including endoscopic retrograde cholangiopancreatography (ERCP), are performed less frequently in children relative to adults. A formal study to evaluate institutional volumes and practice patterns for advanced therapeutic pediatric endoscopy procedures has, however, not been previously undertaken. METHODS A self-administered 16-question (5-minute) online survey assessing practice patterns for performance of pediatric endoscopy procedures was distributed to all registered North American Society for Pediatric Gastroenterology, Hepatology and Nutrition programs. Results were analyzed using descriptive statistics and thematic analysis of free-text comments. RESULTS Respondents from 82.9% of North American Society for Pediatric Gastroenterology, Hepatology and Nutrition centers completed this survey. Responses revealed that esophagogastroduodenoscopy/colonoscopy are performed at the vast majority of centers (>90%), with most performing >50/year. Therapeutic endoscopy procedures are performed less frequently in the pediatric population, with 18.97% reporting that ERCP is not performed at their institution. Where ERCP is performed, 91.38% reported <25/year. Endoscopic ultrasound is not performed at more than half (53.33%) of institutions. Approximately 71.67% of respondents do not believe their institution's current arrangement for performing pediatric therapeutic endoscopy procedures is adequate. CONCLUSIONS Although the range of endoscopic procedures performed in children parallels that performed in adults, there are notable differences in pediatric and adult gastroenterologists' endoscopy training and procedure volumes. Our results and respondent comments suggest that pediatric patients would benefit from a partnership between pediatric and adult gastroenterologists, with adult gastroenterologists performing more complex therapeutic endoscopic procedures.
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Overman RE, Hsieh LB, Thomas TT, Gadepalli SK, Geiger J. Pediatric Laparoscopic Common Bile Duct Exploration: An Opportunity to Decrease ERCP Complications. J Surg Res 2019; 242:318-322. [PMID: 31129240 DOI: 10.1016/j.jss.2019.04.072] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 03/25/2019] [Accepted: 04/25/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Laparoscopic intraoperative cholangiogram (IOC) with common bile duct exploration (CBDE) and endoscopic retrograde cholangiopancreatography (ERCP) are two therapeutic techniques for choledocholithiasis. The preferred technique is unclear. MATERIALS AND METHODS We identified subjects who underwent laparoscopic cholecystectomy (LC) and IOC/CBDE or ERCP from July 1, 2006, to December 31, 2016. We retrospectively reviewed 81 patients (≤ 18 y) who received these interventions for suspected choledocholithiasis. Main outcomes analyzed were success of intervention and complications. RESULTS Of the 81 patients, 21 ERCPs and three endoscopic ultrasounds (EUSs) were performed before LC. Eighteen of 21 (85.7%) patients had stones or sludge cleared by ERCP, whereas 3 (14.3%) had normal common bile ducts without evidence of stones. Five of 24 (20.8%) had significant post-ERCP complications. Seven of 24 (29.2%) had more than one admission. Sixty of 81 patients underwent LC with IOC ± CBDE. Twenty one of 60 (36.2%) were found to have abnormal IOC. Eight of 15 (53.3%) attempted laparoscopic CBDE were successful. Eleven of 21 (52.4%) patients with abnormal IOC had post-LC ERCP (10) and EUS (1). Patients admitted to the Pediatric Surgery service were more likely to undergo LC first than ERCP/EUS (OR 3.46, 95% CI 1.26 to 9.45, P = 0.016). Patients undergoing LC first had a shorter length of stay (mean LOS 5.13 d versus 4.07, median 5.0 versus 3.0 d, P-value < 0.05). CONCLUSIONS Successful and safe laparoscopic treatment of choledocholithiasis is possible in the pediatric patient. A laparoscopic-first approach to suspected choledocholithiasis may reduce the number of procedures needed in this patient population.
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Affiliation(s)
- R Elliott Overman
- Department of Surgery, Section of Pediatric Surgery, CS Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan.
| | - Lily B Hsieh
- Department of Surgery, Section of Pediatric Surgery, CS Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Tina T Thomas
- Department of Surgery, Section of Pediatric Surgery, CS Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Samir K Gadepalli
- Department of Surgery, Section of Pediatric Surgery, CS Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - James Geiger
- Department of Surgery, Section of Pediatric Surgery, CS Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
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In-hospital Pediatric Endoscopic Retrograde Cholangiopancreatography Is Associated With Shorter Hospitalization for Children With Choledocholithiasis. J Pediatr Gastroenterol Nutr 2019; 68:64-67. [PMID: 30044307 DOI: 10.1097/mpg.0000000000002102] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Children with choledocholithiasis are frequently managed at tertiary children's hospitals that do not have available endoscopic retrograde cholangiopancreatography (ERCP) proceduralists. We hypothesized that patients treated at hospitals without ERCP proceduralists would have a longer hospital length of stay (LOS) than those with ERCP proceduralists. METHODS Charts were reviewed for patients who underwent cholecystectomy and ERCP at 3 tertiary children's hospitals over 10 years. Trauma and complicated pancreatitis patients were excluded. Comparisons between patients requiring and not requiring transfer for ERCP were made using Wilcoxon rank-sum tests for continuous variables and Fisher's exact tests for categorical variables. RESULTS One hundred and sixty-four children underwent ERCP for suspected choledocholithiasis: 79 (48%) in the transfer group and 85 (52%) in the no transfer group.Median LOS was longer for patients requiring transfer (7 vs 5 days, P < 0.0001). One-third (34%) of the transfer patients had magnetic resonance cholangiopancreatography compared to only 7% that did not require transfer (P < 0.0001). Among the 123 patients who underwent ERCP before cholecystectomy, 53% required (66/123) transfer and 47% (57/123) did not. Transfer group patients had longer median hospital LOS (P < 0.0001), more days between admission and ERCP (P < 0.0001), and more days between ERCP and surgery (P = 0.0004). CONCLUSIONS Overall median LOS was significantly shorter for patients who underwent ERCP at the admitting facility. Patients who underwent ERCP before cholecystectomy at hospitals without available ERCP proceduralists incurred longer LOS. There is a need for more pediatric proceduralists appropriately trained to perform ERCP in children.
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Yu PT, Fenton SJ, Delaplain PT, Vrecenak J, Adzick NS, Nance ML, Guner YS. Management of choledocholithiasis in an infant. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2018. [DOI: 10.1016/j.epsc.2017.10.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Zerey M, Haggerty S, Richardson W, Santos B, Fanelli R, Brunt LM, Stefanidis D. Laparoscopic common bile duct exploration. Surg Endosc 2017; 32:2603-2612. [DOI: 10.1007/s00464-017-5991-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Accepted: 11/26/2017] [Indexed: 12/16/2022]
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13
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SAGES clinical spotlight review: intraoperative cholangiography. Surg Endosc 2017; 31:2007-2016. [PMID: 28364147 DOI: 10.1007/s00464-016-5320-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Accepted: 10/31/2016] [Indexed: 12/19/2022]
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Schwab B, Rooney DM, Hungness ES, Barsness KA. Preliminary Evaluation of a Laparoscopic Common Bile Duct Simulator for Pediatric Surgical Education. J Laparoendosc Adv Surg Tech A 2016; 26:831-835. [PMID: 27607145 DOI: 10.1089/lap.2016.0248] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE Laparoscopic common bile duct exploration (LCBDE) decreases overall costs and length of stay in patients with choledocolithiasis. However, utilization of LCBDE remains low. We sought to evaluate a previously developed general surgery LCBDE simulator among a cohort of pediatric surgical trainees. The study purpose was to evaluate the content validity of an LCBDE simulator to support or refute its use in pediatric surgery education. MATERIALS AND METHODS After IRB exempt determination, 30 participants performed a transcystic LCBDE using a previously developed simulator and evaluated the simulator using a self-reported 28-item instrument. The instrument consisted of two primary domains (Quality and Ability to Perform) that were rated using twenty-five 4-point rating scales and one 4-point global rating scale. Validity evidence relevant to test content was evaluated using a many-facet Rasch model. Interitem consistency was estimated using Cronbach's alpha. P < .05 was considered statistically significant. RESULTS The highest combined observed averages were for the Value subdomain (OA = 3.79), whereas the lowest ratings were for the Physical/visual attributes subdomain (OA = 3.19). The averaged global rating was 3.14, consistent with this simulator can be considered for use in pediatric LCBDE training, but could be improved slightly. Rasch indices were favorable and supported evidence relevant to test content. Interitem consistency estimates were also favorable, with α values of 0.94 and 0.56 for Qualities and Ability, respectively. CONCLUSIONS Overall, participants rated the LCBDE simulator highly valuable for pediatric surgical education and felt that it could be used as an educational tool with minor modifications.
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Affiliation(s)
- Ben Schwab
- 1 Department of Surgery and Medical Education, Northwestern University Feinberg School of Medicine , Chicago, Illinois
| | - Deborah M Rooney
- 2 Department of Learning Health Sciences, University of Michigan Medical School , Ann Arbor, Michigan
| | - Eric S Hungness
- 1 Department of Surgery and Medical Education, Northwestern University Feinberg School of Medicine , Chicago, Illinois
| | - Katherine A Barsness
- 3 Department of Surgery and Medical Education, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine , Chicago, Illinois
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Abstract
Biliary disease in children has changed over the past few decades, with a marked rise in incidence-perhaps most related to the parallel rise in pediatric obesity-as well as a rise in cholecystectomy rates. In addition to stone disease (cholelithiasis), acalculous causes of gallbladder pain such as biliary dyskinesia, also appear to be on the rise and present diagnostic and treatment conundrums to surgeons.
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Affiliation(s)
- David H Rothstein
- Department of Pediatric Surgery, Women and Children׳s Hospital of Buffalo, 219 Bryant St, Buffalo, New York 14222; Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
| | - Carroll M Harmon
- Department of Pediatric Surgery, Women and Children׳s Hospital of Buffalo, 219 Bryant St, Buffalo, New York 14222; Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York.
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